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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r"Cvi 50cSu �Z2 <br /> OWNER/ OPERATOR <br /> GL <br /> x �- <br /> Gl �Q p�� ( L/r an `•i rJl CHECK If BILLING ADDRESS <br /> FACILITY NAME ei' ry O )`l CA K 0> 1^^ O s � CJ' I c' <br /> SITE ADDRESS 'q � �`�� 14 1r � Y lit- TAyL0r'(� 45-3s� <br /> Street Number Direction ' V Str t Name t V x cI V ^ 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -Z?] j�-*✓��J2f'wt-(nom 1 y- <br /> Street Number e f" Street Name <br /> CITY �\ oAt5� STATE /yx` ZIP <br /> PHONE#1 0 "\. APN# LAND USE AAP"PLICATION If ? <br /> (IM 324-10g--z <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C�Aev�jfq ',/-ve/10i/L �CHECK if BILLING <br /> ILLING CADDRESS <br /> BUSINESS NAME q'lnlCn O ^ OJw-,- o / ' <br /> HOME or MAILING ADORES (AX#23 -9 IOv-. ) <br /> CITY c,^ <br /> STATE C/CN- ZIP s C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of dame, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fom1. <br /> I also certify that.I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �iWLJ� T, (bI 12C-7 <br /> . <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner Or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is availablPANION1r time it Is <br /> provided to me or my representative. ` ' <br /> TYPE OF SERVICE REQUESTED: O x1-e Kk(� ` YDS <br /> COMMENTS: JU <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service ampleted (if already completed): SERVICE CODE: nv <br /> I P/E: U <br /> Fee Amount: 5 _ Amount Paid 5 a Payment Date / 2 . <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> , <br />